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MARION COUNTY PUBLIC WORKS AGI—00/2-110 <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PW/Buildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, C lCrna`, Let.) Co. ,have authorized <br /> (Prperty pwner/Print Name) <br /> re..J 15-e II to act as my agent in performing the <br /> (Authorized Representative/Print Name) <br /> activities necessary to obtain site evaluations,permits, and other onsite wastewater treatment program <br /> services provided by the Department of Environmental Quality or County Agent on the property <br /> described below in accordance with OAR chapter 340, division 071. <br /> PROPERTY IDENTIFICATION: <br /> 5 2 33 Xee e Li NE 6ertAti5 oZ 97c�ZZ <br /> 52-3S- Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description 16 19 3 Tax Lot#(s) Z Q o1700 <br /> PROPERTY OWNER: <br /> Printed Na e: o f G".��, ,� Co. <br /> Signature: 0,44A. �� Date: <br /> Address: P, 0, I3cc $"6 Phone: soy-30-73'7i <br /> City, State,Zip SI. ,4 OR 97 137 Fax: s'o 3-38-3- ?r7y <br /> E-mail Address Di, () Co(e,t - 5a,.ake <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: 'Pr ) 13e/ I <br /> Company Name: COk.,,,oa L I 6. <br /> Signature: _/ _.„," Date: 41/(L( /( F <br /> Address: .d t .to Q'/ Phone: <br /> City, State, Zip j/(,f',../ 97/3'7 Fax: <br /> E-mail Address Dr-1 _)(_('e/e,,,,0._se d DEQ License License# CCB # <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />